Please complete the form below, and press the Enroll button.
Select Title ...MrMasterMissMrsMsDr
Select Sex at Birth ...FemaleMale
Select Gender Identity ...FemaleMaleNon-binaryGender DiverseTransgenderDifferent IdentityDo not wish to provide
Do you identify as Aboriginal or Torres Strait Islander? NoAboriginalTorres Strait IslanderBoth Aboriginal and Torres Strait Islander
Do you smoke ...No0 – 10 per day10 – 25 per dayOver 25 per day
Do you drink alcohol...1-2 glasses/cans per day2-5 per dayMore than 5 per dayNon-Drinker
Stratford Medical Centre and Wheels of Wellness participate in Quality Improvement involving the sending of de-identification information for Health Data. Please inform reception if you do not wish to participate.
Your medical record is a confidential document. It is always the policy of this practice to maintain the security of personal health information and to ensure that this information is only available to authorised members of staff.
Please refer to our Privacy Policy located at Reception or via our website.
Do you consent to the Doctors at Stratford Medical Centre uploading and accessing your My Health Record?
Yes
No
Do you wish to receive SMS notifications from Stratford Medical Centre for the following?
Appointment reminders
Clinical Reminders
Clinical Communications (Results & Clinical Messages)
Health Awareness (Leaflets & Database)
Do you consent to the Staff at Stratford Medical Centre sending Emails to you which may contain private/clinical information?
If you request to communicate with us via email, we remind you that this is not encrypted, and we do not send information via this means, without your consent.
Digital Signature
Date
